Sue Panton thought she was having a heart attack.
Her father had just died from cancer, so the physicians treating her said the racing heart was likely due to stress.
In the space of a few months in 2018, the school teacher from Victoria — then 52 years old — visited an emergency department four times.
It turns out she was experiencing heart palpitations, one of more than 30 symptoms of perimenopause identified by the non-profit Menopause Foundation of Canada.
In addition to heart palpitations and hot flashes nearly hourly throughout the day, Panton was battling recurrent urinary tract and bladder infections — on top of really challenging gastrointestinal issues, for which she'd had a battery of tests.
"I was sort of at my absolute wit's end," Panton told White Coat, Black Art.
That's when she started researching her symptoms online and discovered that they could all potentially be linked to the menopause transition. Until then, "I did not connect any of the dots, nor did my doctor."
On the North American Menopause Society website, she found the name of a qualified doctor in her city (there are now five listed in Victoria). Panton got a referral from her family physician, who she said recognized he didn't know how best to help manage her hormones.
'Who prepares women for this?'
Physicians say lack of information and poor access to doctors who have received specialized training on menopause have left most women without the tools they need to manage what can sometimes amount to debilitating symptoms.
It's a systemic problem that needs a solution, starting with a whole lot more conversation about it, said Dr. Iris Gorfinkel, who helps patients with perimenopause symptoms at her Toronto family medical practice.
"Who talks about it? Who prepares women for this? For most of us, it comes on as a big surprise," said Gorfinkel, who counts herself among those who have found the menopause transition unexpectedly difficult, despite being a female physician.
Sure, most people know to expect hot flashes, she said, but the severity can still be a shock until you've experienced them yourself.
Because of demands on their time, it can be hard for primary care physicians to proactively chat with each of their patients ahead of the perimenopausal years about what to expect, Gorfinkel said.
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But if women can come to an appointment armed with a few brief notes on the symptoms they're experiencing, such as hot flashes, insomnia and memory loss — and on the frequency and severity — it can help their doctor identify appropriate treatments, she said.
These range from various forms of oral and topical hormone therapies, to anti-anxiety and antidepressant medications, sleeping pills and even advice around nutrition, exercise and other lifestyle changes.
Outdated information about hormone therapy
Among the barriers to getting help, Gorfinkel said, is outdated information on hormone replacement therapy for menopausal symptoms, referred to more recently as menopausal hormone therapy.
A lot of that incomplete information can be traced back to how a study called the Women's Health Initiative (WHI) was reported on back in 2002, when it found a very slight increased incidence of breast cancer, she said.
Where previously hormone replacement therapy had been widely embraced, often espoused as a way to be "feminine forever," news of the study's findings caused prescriptions to plunge, Gorfinkel said. Two decades later, there's still a lot of reticence over its use.
"I hate to say it, but doctors themselves sometimes do not understand how little risk there is with hormonal replacement to treat severe hot flashes ... and that lack of understanding is preventing women from getting the therapy they need."
Dr. Wendy Wolfman, a Toronto gynecologist and president of the Canadian Menopause Society, concurs.
The WHI study found that among women aged 50 to 59, there were six additional breast cancers in 10,000 women, "which is considered a rare event," said Wolfman, who is also the director of menopause and premature ovarian insufficiency clinics at Sinai Health System in Toronto.
"And this doesn't evaluate any of the quality-of-life issues — the hot flashes, the sleep disruption, the mood changes that are all benefited by hormone therapy. So my attitude towards this is if you are severely being affected by your symptoms, why wouldn't you take something that has such a tiny risk and yet provides such a huge benefit?"
What's happening in the body at mid-life
Wolfman said it's helpful for women to understand that the symptoms they experience around menopause are "because of the loss of eggs, and the cells around those eggs, that produce the estrogen."
As a result, women can experience hot flashes, night sweats and vaginal dryness, as well as sleep disruption, mood swings, decreased sexual desire and a host of other symptoms, she said.
There is also an inappropriate stimulation of the areas within the brain that manage heat control, she said. Because our cardiovascular and circulatory systems have to work hard to bring body temperature back into a normal range, a hot flash "may not be an innocuous event" that women should simply tolerate, Wolfman said.
Protecting the heart
Rebecca Thurston, a psychiatry professor at the University of Pittsburgh who has done extensive research on the connections between menopause and women's cardiovascular health, said it's not yet known if hot flashes are causing cardiovascular disease in women.
But her research and that of others has shown that people who experience frequent hot flashes and night sweats — known together as vasomotor symptoms — have more buildup of plaque in their arteries and more thickening of the walls of the vessels, she said.
"This is the time now to start taking care of your cardiovascular health, so all of those good heart-healthy behaviours we know we should be doing — whether it's starting that exercise program, stopping smoking, controlling weight gain," said Thurston, who has a PhD in clinical health psychology.
"Cardiovascular disease is the leading cause of death in women. Women tend to think it's breast cancer, but it's not."
Thurston said it's important to note that researchers don't yet know if hormone therapy works as a treatment to improve cardiovascular health — only that arterial plaque and thickened vessels are correlated with frequent hot flashes or night sweats.
Tailoring hormone therapy
When prescribed appropriately, Gorfinkel said, menopausal hormone therapy can help with hot flashes, sleep disturbance, vaginal dryness and genitourinary symptoms, such as urinary tract infections. It can also slow both the loss of bone density, which helps prevent fractures, and the development of Type 2 diabetes.
Hormone therapy is also not right for everyone, and it must be tailored to the symptoms experienced by those with menopause and to their risk profile.
Except for those who have had a hysterectomy, estrogen must be prescribed along with progesterone to protect against uterine cancer, Wolfman said.
But estrogen isn't the only hormone that drops off during the menopause transition, nor is it the only one on the table for those seeking relief from menopausal symptoms.
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Declining sex drive
Prior to perimenopause, women have testosterone in their bodies at even higher levels than estrogen, Wolfman said. Declining levels of testosterone can be behind a number of symptoms, including lack of sex drive.
It was one of the issues that Julie Smith of Halifax faced. She went to her doctor and said, "I'm losing sleep, I'm cranky, I'm irritable. My sex life ... was, you know, none because I just couldn't handle, you know, my body heat was just too uncomfortable."
That put a major strain on her marriage. Smith said she eventually asked her doctor to chat with her husband to help him understand what she was going through.
Unfortunately, it's not that easy for women to get their hands on appropriate testosterone treatments. The only country in the world that has an approved testosterone product specifically for women is Australia, Wolfman said. "In the U.S., for instance, there are 33 products approved for men."
Women can get testosterone through compounding pharmacies, but a precise dose isn't always guaranteed, costs tend to be higher and it can be difficult to get coverage from insurance companies.
Although finding the right treatment for managing symptoms through the menopausal transition can take some trial and error, it's worth doing so that the many demands at this stage of life can be met — from responsible jobs to caring for both children and aging parents, Thurston, of the University of Pittsburgh, said.
"I would say don't let yourself suffer. So if you are suffering, absolutely get help. You probably can get help with many of these symptoms that you're experiencing, and there's no need to do it alone."
Produced by Colleen Ross.
